PhD Candidate University of Alberta Edmonton, Alberta, Canada
Background: Despite progress in the field, cardiovascular disease remains the leading cause of death for women globally. Antiplatelet medications remain essential in managing atherosclerotic cardiovascular disease. Females metabolize pharmacotherapy differently at pharmacokinetic and pharmacodynamic levels compared to males, and biological sex and sex steroid hormones may influence platelet activity. Yet, the clinical guidelines endorse a one-size-fits-all approach. We assessed female representation in the antiplatelet medication literature informing the 2023 Canadian Antiplatelet Guidelines.
METHODS AND RESULTS: Literature cited in the 2023 Canadian Antiplatelet Guidelines and its supplemental materials was systematically reviewed. Experimental and observational research, systematic reviews and meta-analyses were included. Guidelines, consensus documents, studies missing demographic data and research protocols were excluded. Extracted data included study title, author, year, design, sample size, mean participant age and proportion of females. The guidelines contain seven PICO questions. The data was analyzed by PICO question, and overall, see Table 1. Of 143 unique citations, 118 were included. Most studies were published in the last decade (64%), less than one-third between 2004 and 2014 (30%) and few before 2004 (7%). From the included evidence, the total sample size was 834,934 (28.7% female), with a mean age of 65.4 years. Of the included studies, only 25 (21%) had adequate female representation (participation-to-prevalence ratio (PPR) of 0.8 to 1.2); females were underrepresented in 86 (73%) (PPR less than 0.8), and females were overrepresented in 7 (6%) (PPR greater than 1.2). Only two PICO questions had adequate female representation: ‘The use of ASA in primary prevention of ASCVD’ (PPR 1.1) and ‘The choice and duration of DAPT in ACS patients who are medically treated without revascularization (PPR 0.8).’
Conclusion: Females were not adequately represented in nearly two-thirds of the evidence. The 2023 guidelines are primarily informed by evidence that only had adequate male representation or overrepresentation. There remains a need for greater attention to adequately representing females in clinical trials for antiplatelet medications. Having the ability to look at sex-stratified data would provide clinicians with the opportunity to choose medications based on trial evidence.
